|NIOSH In-house FACE Report 2003-07
February 12, 2004
On January 28, 2003, two Hispanic construction laborers [15 and 16-year-old
brothers] (the victims) died when the trench they were working in experienced
a cave-in. The victims were members of a crew installing conduit in an
eight-foot-deep by two-foot-wide trench. When work started, the jobsite
foreman instructed the crew leader to operate a backhoe to dig the trench.
The foreman then left the site to check on another job. After approximately
an hour, the crew leader grounded the bucket, turned the machine off and
walked to the company trailer to check blueprints. As he was looking at
the blueprints, he heard loud voices outside the trailer from the direction
of the ditch. As he exited the trailer, he was informed by one of the
workers that the trench had collapsed and that the two employees had been
covered up. The emergency medical squad (EMS) was summoned and responded
within minutes. Coworkers had uncovered the victims and removed them from
the trench as the rescue squad arrived. The victims could not be revived
and the county coroner was summoned to the scene where he pronounced the
NIOSH investigators concluded that, to help prevent similar occurrences,
- ensure that a competent person conducts daily inspection of excavations,
adjacent areas, and protective systems and takes appropriate measures
necessary to protect workers
- ensure that workers are protected from cave-ins by an adequate protective
- develop, implement, and enforce a comprehensive written safety program
for all workers which includes training in hazard recognition and the
avoidance of unsafe conditions
- pursue every effort to ensure that documentation of age is authentic
and that youth < 18 years of age are not assigned to prohibited tasks
and are appropriately supervised
- ensure that workers who are part of a multilingual workforce comprehend
instructions in safe work procedures for the tasks to which they are
- ensure that only qualified rescue personnel who have assumed responsibility
for rescue operations and site safety should attempt rescue operations.
On January 28, 2003, two Hispanic construction laborers [15 and 16-year
old brothers] (the victims) died when the trench they were working in
collapsed. On February 3, 2003, the National Institute for Occupational
Safety and Health (NIOSH), Division of Safety Research (DSR), was notified
of the incident by the U.S. Department of Labor, Wage and Hour Division.
On February 11-13, 2003, a DSR lead occupational safety and health manager
conducted an evaluation of the incident. The incident was reviewed with
the Federal and State Departments of Labor; Wage and Hour Divisions; the
South Carolina Occupational Safety and Health Administration; the county
coroner and sheriff’s offices; the company owners; and, the Director
of the South Carolina Hispanic Leadership Council. A site visit was conducted,
and pictures taken immediately after the incident were provided by the
county coroner. The county sheriff and coroner reports were reviewed,
and documentation of the victims’ ages was examined.
The employer was an electrical contractor that had been in operation
for 10 years and employed 65 workers, 11 at the incident site. Twenty-two
new company hires started the day of the incident at various job sites.
None of these employees had received any orientation or training by the
company. The employer had been awarded a multi-million dollar contract
to provide all electrical work at the site of a new high school under
construction. The contract was awarded by a site project management company
hired by the school district. The employer was one of six companies acting
as prime contractors at the site. Prior to this job, the employer specialized
in residential wiring. The employer had no formal safety and health program
and, until the incident, employees received only on-the-job training.
Since the incident, the employer has hired a safety consultant to develop
a comprehensive safety and health and training program, and employees
have completed the OSHA ten-hour course and received OSHA training in
trenching operations. Company policy now dictates that all employees receive
this training. These were the first fatalities experienced by the company.
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The employer had been contracted to perform all the electrical work at
the site of a new two-story 390,000 square-foot high school under construction.
The company had been on site for two weeks and was in the process of installing
electrical, data, and communication conductors encased in conduit for
the schools data bank and communication system in a 2-foot-wide by 8-foot-deep
trench. The composition of the soil at the site was backfill that was
sandy with some clay. Soil-type classification tests had not been conducted
at the time of the investigation. The electrical conduit was installed
at the bottom of the trench then back-filled with 18 inches of soil. The
data and communication conduit was then installed and covered (Photo
1). The plumbing would then be installed over the data and communication
conduit. These would all be located underneath the footings for the foundation
of the school.
Photo 1. Location of conduit;
of county coroner
On Monday January 20, 2003, four Hispanic workers arrived
at the site and approached the job foreman to inquire about the availability
of work. One of the men spoke English and acted as an interpreter for
the others. The foreman informed them that there was nothing available
at the time, but to check back at the end of the week. On Friday January
24, the men returned to the site and were given applications, tax forms,
terms of employment paperwork, and were instructed by the foreman to complete
the forms and to return to the site the following Monday for work. On
Monday January 27, the men returned to the site and all four were hired
by the foreman. All had resident alien and social security cards. Documents
presented by the victims indicated both were 22 years old. Ages of the
other two workers were listed as 21 and 29 years.
On the following day, the crew began work at 7:00 a.m. The foreman instructed
the crew leader as to the work to be performed that day, including the
trenching operations and the area and direction in which the conduit-encased
conductors would be installed, then left the site to check on other jobs.
The crew leader, who did not speak Spanish, relayed the instructions to
English- speaking crew members while the bi-lingual worker translated
the instructions to the Hispanic workers on the crew. The crew leader
went to the company trailer to check the blueprints to determine the correct
direction to excavate the trench as the rest of the crew gathered the
supplies that would be needed that day.
The crew leader then began to excavate the trench as some of the crew
stood along the side of the trench while others performed cleanup and
various other duties. Shortly after 8:00 a.m., the crew leader grounded
the bucket of the rented backhoe, shut the machine down, and returned
to the trailer to double check the blueprints. While in the trailer, he
heard loud voices coming from the direction of the trench. As he exited
the trailer, he was informed by a crew member that the trench had collapsed
and two workers had been covered up. (Photo 2) The
crew leader immediately called 911, then ran to the trench to assist the
crew in uncovering the trapped workers. The workers uncovered the victims
and removed them from the trench. When 911 personnel arrived minutes later,
they could detect no vital signs and due to the visible injuries summoned
the county coroner, who pronounced the victims dead at the scene.
The reason for the victims being in the trench could not be determined.
The crew leader had not instructed anyone at that time to enter the trench.
A statement that one of the other Hispanic workers had restarted the machine,
which was positioned on the side of the ditch opposite the cave in, and
resumed digging could not be substantiated at the time of the NIOSH investigation
or by OSHA investigators. The position of the backhoe was not considered
a causative factor in the incident.
Photo 2. Location of the victims;
courtesy of county coroner
Two days after the incident, the parents arrived at the funeral home
where the victims were taken and presented the funeral director with birth
certificates listing the victims’ ages as 15 and 16 years of age.
The victims had been in the United States for a little over a year and
had worked at other construction sites. This information was forwarded
to the county coroner, who forwarded it to the proper authorities.
The credentials presented by the victims to the site foreman at the time
of their hire were closely examined and were determined not to be authentic.
Cause of Death
The coroner listed the cause of death for both victims as basilar hinge
fractures of the skull.
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Recommendation #1: Employers should ensure that a competent person conducts
daily inspection of excavations, adjacent areas, and protective systems
and takes appropriate measures necessary to protect workers.
Discussion: Significant hazards are associated
with trenching operations, including cave in, positioning of machinery,
and changes in environmental and physical conditions. For these reasons,
29 CFR 1926.651 (k) (1)1 requires that
“daily inspections of excavations, the adjacent areas, and protective
systems shall be made by a competent person* for evidence
of a situation that could result in possible cave-ins, indications of
failure of protective systems, hazardous atmospheres, or other hazardous
conditions. An inspection shall be conducted by the competent person prior
to the start of work and as needed throughout the shift.” 29 CFR
1926.651 (k) (2)1 requires that “where
the competent person finds evidence of a situation that could result in
a possible cave-in, indications of failure of protective systems, hazardous
atmospheres or other hazardous conditions, exposed employees shall be
removed from the hazardous area until the necessary precautions have been
taken to ensure their safety.” No competent person was on site or
made daily inspections in this case.
Recommendation #2: Employers should ensure that workers are protected
from cave-ins by an adequate protective system.
Discussion: The applicable OSHA Excavation
Standard, 29 CFR 1926.652 (a) (1)1 states
that “each employee in an excavation shall be protected from cave-ins
by an adequate protective system.” A protective system designed
for the soil conditions found in this excavation could have included a
trench shield (also known as a trench box), shoring, or a combination
of shoring and shielding. Sloping would not have been appropriate because
of the sandy composition of the back-filled soil. Employers should consult
tables located in the appendices of the OSHA Excavation Standard that
detail the protection required based upon the type of soil and environmental
conditions present at the site. Employers can consult with manufacturers
of protective systems to obtain detailed guidance for the appropriate
use of these products. In this incident, no protective system had been
placed at any point in the trench.
Recommendation #3: Employers should develop, implement, and enforce a
comprehensive written safety program for all workers which includes training
in hazard recognition and the avoidance of unsafe conditions.
Discussion: Employers should evaluate all
tasks performed by workers, identify all potential hazards, then develop,
implement, and enforce a written safety program addressing these hazards.
Additionally, according to 29 CFR 1926.21(b)(2)1
“the employer shall instruct each employee in the recognition and
avoidance of unsafe conditions and the regulations applicable to their
work environment to control or eliminate any hazards or other exposure
to injury or illness.” Youth less than 18 years of age should receive
additional training on prohibited work tasks and settings (activities
deemed to be especially dangerous for youth by the employer and/or child
labor regulations), as well as hazards and safe work practices that apply
to work they are permitted to perform. The victims had not received any
training from the employer, and there was no evidence that they had ever
received any type of training. Construction sites expose workers to multiple
and complex hazards. It cannot be assumed that employees, especially new
hires, can recognize hazards such as working in an unprotected trench,
to which they are being exposed. Training in recognizing and avoiding
hazards should be given to all workers, coupled with employer assessments
that workers are competent in the recognition of hazards and safe work
Recommendation #4: Employers should pursue every effort to ensure that
documentation of age is authentic and that youth < 18 years of age
are not assigned to prohibited tasks and are appropriately supervised.
Discussion: Employers should consider requiring
applicants to report to the company office to fill out applications and
present documentation of age. This documentation should be carefully examined
for authenticity. Employers should also consider requiring multiple forms
of official documentation of age. During examination of the victims’
documentation in the coroner and sheriff’s office, numerous imperfections
were identified. The employer had not yet completed the U. S. Department
of Justice, Immigration and Naturalization Service, Form I-9 (Employment
Eligibility Verification Form) for the new employees. Employers have three
business days to do so. The workers had been with the company for only
two days. Guidelines for the verification of employment eligibility of
new employees can be obtained from the U. S. Department of Justice, Immigration
and Naturalization Service.2
Once the authentic age of a worker is determined, employers should not
assign youth < 18 years of age to tasks considered too dangerous for
youth, and should ensure that youth are appropriately and constantly supervised.
The Fair Labor Standards Act provides a minimum age of 18 years for non-agricultural
work which the Secretary of Labor declares to be particularly hazardous
(Hazardous Orders). One of the 17 Hazardous Orders prohibits minors from
performing some types of work in excavation operations (Hazardous Order
No.17).3 Specifically, this order prohibits
the employment of persons less than 18 years of age from excavating, working
in, or backfilling trenches that are 4 feet deep or greater at any point.
Additionally, youth 15 years of age may not be employed in any occupation
involved in construction, except office or sales work.
Employers who employ workers less than 18 years of age should contact
the U.S. Department of Labor Wage and Hour Division and the agency in
their State that regulates child labor to obtain information regarding
appropriate work assignments for young workers (http://www.dol.gov/whd/) (Link updated 1/7/2010).
A NIOSH Alert, Preventing Deaths, Injuries, and Illnesses of Young
Workers4 provides additional information
regarding appropriate work assignments for young workers.
Recommendation #5: Employers should ensure that workers who are part of
a multilingual workforce comprehend instructions in safe work procedures
for the tasks to which they are assigned.
Discussion: Companies that employ workers
who do not understand English should identify the languages spoken by
their employees, and design, implement, and enforce a multi-language safety
program. To the extent feasible, the safety program should be developed
at a literacy level that corresponds with the literacy level of the company’s
workforce. The program, in addition to being multi-language, should include
a competent interpreter to explain worker rights to protection in the
workplace, safe work practices workers are expected to adhere to, specific
safety protection for all tasks performed, ways to identify and avoid
hazards, and who they should contact when safety and health issues arise.
Recommendation #6: Employers should ensure that only qualified rescue
personnel who have assumed responsibility for rescue operations and site
safety should attempt rescue operations.
Discussion: Although not a factor in this
incident, no rescue plan for the site existed and untrained coworkers
uncovered and removed the victims from the trench before trained rescue
personnel arrived at the scene. Workers should never, under any circumstances,
enter a hazardous environment to attempt a rescue operation unless properly
equipped and trained in the use of the equipment and methods required
for rescue. In this instance, untrained workers entered the trench, uncovered
the victims and removed them from the trench, placing themselves at risk
of becoming victims themselves. Only those persons trained in the requirements
of NFPA 16705 should attempt rescue operations
after a trench cave in occurs. All persons at the incident site should
follow the directions given by the Incident Commander or his/her designee
in order to provide the most optimal circumstances for the safety of all
persons on the site during rescue operations.
Site project management companies should consider ensuring
through contract language that contractors have a comprehensive safety
and health program that addresses all aspects of the jobs they are to
Discussion: Site project management companies
should consider using contract language that requires all contractors
to identify how they intend to implement a site-specific safety and health
program prior to the initiation of work. Contractors’ safety and
health programs should be consistent and compatible with the work to be
performed. The contract should contain clear and concise language as to
which party is responsible for a given safety or health issue. Any differences
should be negotiated before work begins. Once the provisions for these
responsibilities have been established, the respective parties should
ensure that the provisions of the contract regarding safety and health
* Competent person
is defined by OSHA as one who is capable of identifying existing and predictable
hazards in the surroundings or working conditions which are unsanitary,
hazardous, or dangerous to employees, and who has the authorization to take
prompt corrective measures to eliminate them.
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- 29 CFR 1926 (2003) Code of Federal Regulations, Washington D.C.: U.S.
Government Printing Office, Office of the Federal Register.
- U.S. Department of Justice, Immigration and Naturalization Service
. Handbook for Employers, Instructions for Completing Form
I-9 (Employment Eligibility Verification Form). [http://www.uscis.gov/sites/default/files/files/form/m-274.pdf (Link updated 11/12/2013)]
Accessed February, 2004.
- DOL (1990b). Child labor requirements in non-agricultural occupations
under the Fair Labor Standards Act. Washington D.C.: U.S. Department
of Labor, Employment Standards Administration, Wage and Hour Division
- NIOSH . NIOSH Alert: Preventing deaths, injuries, and illnesses
of young workers. Cincinnati, OH: U.S. Department of Health and Human
Services, Public Health Service, Centers for Disease Control and Prevention,
National Institute for Occupational Safety and Health, DHHS (NIOSH)
Publication No. 2003-128.
- NFPA . NFPA 1670, Standard on operations and training for technical
rescue incidents 1999 Edition, Chapter nine, trench and excavation.
Quincy, MA; National Fire Protection Association.
This investigation was conducted by Virgil J. Casini, Lead, Safety and
Occupational Health Manager, Fatality Assessment and Control Evaluation
Team, Surveillance and Field Investigations Branch, Division of Safety